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Currently, about 10% of patients required unplanned readmissions within 30 days after discharge.1 2 This proportion has not changed substantially over the past several years despite intense efforts to improve the discharge process.
Although several studies3 4 have been performed, including patients’ and physicians’ opinion on the preventability of readmissions and factors that would predict preventability, only a few studies have included nurses’ opinions and the consensus with all stakeholders.5 We aimed to determine the patient’s opinion on preventable readmission, associated factors and the extent to which patients, nurses and physicians agree on readmission preventability.
To achieve the proposed objectives, a descriptive transversal correlational multicentre study was developed. This study was approved by the Clinical Research Ethics Committee (reference number: PR114/17). From 2 April 2017 to 18 January 2019, all patients readmitted within 30 days to 2 medical and 2 surgical departments (internal medicine, pneumology, trauma and digestive surgery) at 4 university hospitals were identified. Patients who provided written informed consent were interviewed within 72 hours of readmission. Four research nurses were trained to deliver the interviews. The patient’s interview involved 23 questions6 about functional status at discharge, discharge process and follow-up care, including readmission preventability (online supplemental material). Two independent physicians and nurses of the research team concurrently reviewed electronic health records to identify factors contributing to potentially preventable readmissions.7 Clinical and demographic patients’ characteristics were also collected.
We estimated that a total sample size of 276 patients was needed for a proportion of 11% of preventable readmission,7 95% confidence level and 0.04 precision and assuming 15% potentially missed cases. A logistic regression model has been used to assess the association between the patient profile and his answer to the main question of his readmission preventability. The conditions of application of the models have been validated and CIs at 95% of the estimator have been calculated whenever possible. Cohen’s kappa statistic has been calculated to assess the concordance between physicians’, nurses’ and patients’ answer to this preventability readmission question. All the analysis has been done with the statistic package R V.3.5.3 (11 March 2019) for Windows.
Patients were not involved in the design, conduct, reporting or dissemination plans of this study.
We assessed 805 consecutive patients for eligibility, of whom 529 were excluded refused or unavailable (314 presented haemodynamic instability, 107 were discharged early, 104 refused to participate and four had language barrier). Among 276 patients included, 44.2% were admitted to internal medicine, 13.8% pneumology, 8% trauma and 34.1% digestive surgery department, respectively. The mean age was 68 years and 65.9% were men. The median (IQR) time between discharge and readmission was 11 days (5–17 days) and the median (IQR) Charlson comorbidity index was 5 (3–6).
Ninety-six (34.8%) patients reported that their readmission was preventable, 69 (25.0%) were undecided and 111 (40.2%) reported that their readmission was not preventable. Comparing patients who reported non-preventable readmissions to those who reported preventable readmissions or were undecided, the latter had less time between discharge and readmission, did not have a follow-up appointment scheduled with primary care or specialist at discharge, no medication reviewed and felt concerns were not addressed before discharge. Also, patients who were less satisfied with the hospital’s discharge team, who felt were discharged before being ready and felt concern during follow-up care were more likely to report preventable readmission or undecidedness (table 1).
Among patients who reported a preventable readmission or were undecided, physicians’ reviewers agreed 19.6% and nurses’ reviewers agreed 22.8% of the time, identifying physicians or nurses agreed 31.2% of the cases reported. The overall agreement was 55.4% (Cohen’s κ=0.12; 95% CI, 0.01–0.23). Care during index stay and follow-up care were the most common factors identified by physicians and nurses (table 2).
The results of this study are consistent with previous reports, which have found that almost one-third of patients believed that their readmission was preventable,6 and the associated factors were linked to the discharge process and follow-up care. Furthermore, although the patient and healthcare professionals’ preventability agreement were slight, this percentage increases when the opinion of nurses was considered. These findings must be interpreted in the context of our study design because the limitations of this study include the recall bias of patients’ interviews.
Therefore, the results support the argument that actually the patient’s understanding about their diagnosis and education prior discharge was suboptimal.8 Future studies should evaluate the impact of strategies to improve the transition of care that incorporate the patients’ and nurses’ opinion about readiness to discharge.
This study was approved by the Clinical Research Ethics Committee of Hospital Universitari de Bellvitge (reference number: PR114/17).
We want to thanks the other collaborators at Hospital Universitari de Bellvitge: Hugo Rodríguez-Fernández, Maribel González-Samartino, Marta Tapia-Pérez, Maria-Magdalena López-Jiménez, Emilio Jiménez-Martínez; at Hospital Universitari Arnau de Vilanova: Pilar Ricart and Esther Gomis-Treig; at Hospital Universitari de Girona: Josep Trueta, Heleni Contreras-Fernandez and Marina Figueras-Besalú; at Biostatistics Unit of Institute of Biomedical Research of Bellvitge: Pau Satorra and Cristian Tebé; and at University of Barcelona: Marta Romero-Garcia, Pilar Delgado-Hito and ARES group in the Catalan Institute of Health Hospitals. Writing assistance was provided by Luis Manuel de Casas Hernandez.
Collaborators ARES group members: Hugo Rodríguez-Fernández, Maribel González-Samartino, Marta Tapia-Pérez and Maria-Magdalena López-Jiménez (Hospital Universitari de Bellvitge); Pilar Ricart and Esther Gomis-Treig (Hospital Universitari Arnau de Vilanova); Heleni Contreras-Fernandez and Marina Figueras-Besalú (Hospital Universitari de Girona Josep Trueta).
Contributors All authors had full access to all study data and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: JA and MEJU. Coordination team: JA. Acquisition of data: DLG, MJRM, CNR, MCP, SAF and ARES group in the Catalan Institute of Health Hospitals. Analysis and interpretation data, and drafting of the manuscript: JA and MEJU. Critical revision of the manuscript for important intellectual content: DLG, MJRM, CNR, MCP, LdlCA and SAF. Statistical analysis: JA and SAF. Obtained funding: LdlCA and JA. Administrative, technical and material support: SAF and MEJU. Study supervision: MEJU. Writing assistance was provided by Luis Manuel de Casas Hernandez.
Funding This study was supported by the Departament de Salut de la Generalitat de Catalunya, Pla estratègic de recerca i innovació en salut (PERIS) 2016-2020 (SLT002/16/00085), Catalunya, Spain, and School of Nursing, Medicine and Health Science Faculty, University of Barcelona (PREI-18-005-I).
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.